The nurse is reviewing laboratory results and nurse’s notes to determine which actions to take at this time. Which actions are appropriate for the nurse to take at this time? (Select all that apply)
Observe for signs of respiratory distress and monitor oxygenation by pulse oximetry.
Keep infant in warmer with bilirubin lights to maintain temperature of 97.6° F (36.4° C).
Monitor temperature.
Continue to monitor glucose levels.
Explain to the mother that the baby’s respiratory rate needs to be below 60 breaths/minute to be able to breastfeed.
Tell the mother that she will need to discuss any concerns with the neonatologist.
Inform the mother that the baby is stable enough to take out of the warmer and bilirubin lights.
Correct Answer : A,B,C,D
Choice A rationale
Monitoring for respiratory distress and checking oxygenation by pulse oximetry are critical in newborns, as they can indicate hypoxemia or respiratory issues requiring prompt intervention.
Choice B rationale
Maintaining the infant's temperature at 97.6°F (36.4°C) using a warmer and bilirubin lights is essential for thermoregulation and treating jaundice, ensuring proper physiological stability.
Choice C rationale
Regular temperature monitoring is vital to detect any signs of hypothermia or hyperthermia, which can indicate underlying health issues and guide appropriate interventions for the newborn.
Choice D rationale
Continued monitoring of glucose levels is crucial for detecting hypoglycemia, a common condition in newborns that can lead to seizures, brain damage, or other severe complications if left untreated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Encouraging breastfeeding every 2 to 3 hours is contraindicated in HIV-positive mothers. Breastfeeding can transmit HIV to the infant despite maternal antiretroviral therapy, thus alternative feeding methods are recommended to prevent viral transmission.
Choice B rationale
Zidovudine administration within 6 to 12 hours after birth reduces the risk of perinatal HIV transmission. Early prophylaxis is crucial for preventing viral replication and reducing the likelihood of the infant acquiring HIV.
Choice C rationale
Administering antibiotics for 7 to 10 days is unnecessary unless there is evidence of bacterial infection. HIV-exposed infants need antiviral prophylaxis to prevent HIV transmission, not routine antibiotic treatment without specific indications.
Choice D rationale
Delaying the initial bath for 1 to 2 days is not recommended as it doesn't impact HIV transmission risk. Immediate skin cleansing can reduce exposure to maternal blood and bodily fluids, thus it’s standard practice to bathe newborns soon after birth.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Seizures can occur due to severe preeclampsia, leading to eclampsia, characterized by generalized tonic-clonic seizures. Magnesium sulfate is often used to prevent seizures in these patients, alongside other monitoring measures.
Choice B rationale
Stroke risk is elevated in preeclamptic patients due to hypertension, endothelial dysfunction, and increased coagulation. Blood pressure control is essential to reduce stroke risk and manage preeclampsia complications effectively.
Choice C rationale
Organ damage, particularly to the liver and kidneys, is a complication of preeclampsia. Elevated liver enzymes and proteinuria indicate hepatic and renal involvement, necessitating close monitoring and potential intervention to mitigate damage.
Choice D rationale
Preterm birth is often a result of preeclampsia due to placental insufficiency and maternal health deterioration. Early delivery may be necessary to protect the well-being of both mother and fetus, highlighting the importance of timely diagnosis.
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